GW1-2022-06707_Well Construction - GW1_20220712

PrinfFonr
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
L.Well Contractor Information:
Russell Taylor 14.WATERZONES
%Veil Contractor Name FROat I TO I DESCRIMOt:
z 87'P1 1 Ct. I ft. 'ICJ O-46
fr. 530 ft.
NC Well Contractor Certification Number 15,OUTER CASIilG far multi-cased wells ORL7IYEA ffia Itcable)
Hedden Brothers Well Drilling, inc FROM To DtAhtETER rHtcterEss MATERRI,
ft. I ft. In.
Company Name 16.INNERCASING ORTIIBING eothermal closed-loon)
2.Well Construction Permit: 0?/AG10—9-11(09 I I Moat I To DIA3IETER TMCM-NUS I NATERraL
Ust all applicable Itr l construction permits(t.r-illC,Coratty,State:Varforce,etc) 0 n. I % to in.
ry
3.Well Use(check well use): 51 ft, 159 I . ,88 5I'EE L
Water Supply Well: 17.SCREEN UJ �O
FZrOat To DIASIETER SLOT SIZE THICIMESS aIATERLIL
Agricultural C)Municipal/Public It. ft. in.
Geothermal(Heating/Cooling Supply) §DResidential Water Supply(single) fr. ft. i ia.
IndustriaUCommercial DRcsidtmtial Water Supply(shared) 18.GROUT M
lIrrigation FROaf I TO I MATERLIL I EalPL4CEaIS1Ta[EfHOD S il10LlT
Non Water Supply Well: fL I 20 fL , waen—sa I plumped
Monitoring ORerovery Et. I ft. ,
injection Well:
ft. I fL I
Aquifer Recharge DGmuodwater Remediation 19.SAND/GR+tVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM i TO NUTERIAL I E.IrPWCEDIE\T31ETHOD
Aquifer Test E2-StorrnwaterDrainage ft. 1 fc
r
Experimental Technology DSubsidence Control ft. I ft
Geothermal(Closed Loop) Tracer 20.DR[LLL\G LOG attach addltIoasl sfieets if necessary)Geothermal(Heatin Cooling Remm) iOther[ex lain under#21 Remarks) FROM I TO I D£SCRlPTt0.!color.hardnem:aWrach trp&rmIn sim era)
0 ft. I fL I :Clay S sand
4.Date Well(s)Completed: Well IDr I fr. I fL i ;granite
Cc.
Sa.Well Location:
f
3 a . ft. t-'
r
Faeility/OOwwnerrName (q• � ./ o�J Facility!ID�(if appliicabbllel fr. I ft.
I R� t, Geese. RU. �i; xtrw- aC7 /8- rr. I ft. I
Physical Address,(nC1ityy�.and Zip it.
gOJLSAIJ �..00RI p�t-/+� 121.R$i4L4RKS watt n..n:7 , _c� d n
J y �5�8 5a—BtJID V I �I 1'fvVl l l r• a v v.
County Farccl Identification No.(?IN)
i
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field.One lat/long is sufficient) 22.Certification:
W
6.Is(are)the well(s) Permanent or OTemperar'y Signature ofC%.r ificd Nell Co tractor A Date
By signing th[S font,I hereby certify that r we11(s)was(ivrrr)confMcted in accordance
7.Is this a repair to an existing well: E3Yes or No nith 15A NCdC 03C.0100 or IS.4 NChC 0?C.0300 Yell C-nsmrctfon Srondards and that a
/#'this it a repair,fdl oat known ivell construction hzfornia:!aa ..explain the aatnrr.ofIhr, copy ofthis record has been provided to the well owner.
repair under 021 remark section or air the bar-4-ofthiSfornr.
23 Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1,GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l SUBMITTAL INSTRUCTIONS
//
9.Total well depth below land surface: lf/00 (ft-) 24a. For .411 Wells: Submit this font within 30 days of completion of well
For multiple iellr list all depthsifdierent(trample-3@300'aud2@100') construction to thefollowint:
10.Static water level below top of casing, w (ft•) Division of Water Resources,Information Processing Unft,
!(water love/is above casing,use"=" 1617 tlaii Serice Center,Raleigh,NC 27699-1617
11.Borehole diameter: can.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
L above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: LXC � construction to the followting':
CLe.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Rater Suooly Ig Iniection Wells; In addition to sending the form to
13b.Disinfection type: �S i the address(es) above, also submit one copy of this form within 30 days of
'1 �1 Amount �d_ completion of well consruction to die county health department of the county
y where constructed.
I
Form ON%'-1 North Carolina Depart^ent of Enciroarnan;al Q=lit--Division oft:nevi R:sou:cts Revised 2-22-2016